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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> - APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is reby}a le to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> H Business Name (DBA) - oH� � aOF"I'Address 4o a aS ev o f�!/-C �.3G8fa/y <br /> aOwner—._ .Fi%/ �o.d•Tf� _ Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No, � °2� �:�.�� 3 $.� � Emergency Telephone No. <br /> Contractor Licence No. : - a 47.17 h <br /> L Applicants Name-(Print) - Title � � - Date , <br /> Please check Applicable Category (1-7)and f=ill in the Required Information ., <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, - June 30, 19 - Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location �'� 1 .5 ' <br /> Owner - Md�-� °" 1/a µA _ Address Ao 2 a esc <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑TNEW M REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction i. Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 r <br /> Operator Name �_ Where Certified <br /> Plant Location f <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ' <br /> Eil rf6[tro+ferorts^PtfTrfrsf�p-+ c - r•q r Y -- c `� � . <br /> a rrcriti; Pfotit%,v;n lr r iJ 7 rt17 n <br /> h m " ,magne as 1P be,.(},.,.^ B4 P E Irl': <br /> $?G�Ilt<•i4,r.t-,.FSL'i35$t1B,'w„i{.. .wlr. .d,a.�U i1,F. ... .l�_ ..,D1.,d:�lfr!.dr�o . _ f. hob' .ut 11 :C HCi('�iii.:r.{:�j tlif;'f:u'.i-. 4.'�`:C ,1 . -'r ...�� 1 I ali <br /> hereby certify that I have preparedthisapplication and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X a <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31_ ❑ July 1 &Received By July 31 <br /> 1 BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION- DATE DATE -REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS T <br /> PRORATION - <br /> 1 <br /> PLUS ' <br /> PENALTY - [ <br /> OTHER a <br /> OTHER <br /> Received b Date Receipt No. Permit No. ItsOance Date Mailed Delivered <br /> APPLI NT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES o 1601 E.HAZELTON AVE.,PO.Box 2009 STOCKTON,C1 0 CS <br />